TOPICS IN GERIATRICS:BALANCE AND FALLS
Falls are prevalent in community dwelling older adults, with a higher prevalence in institutionalized older adults; they will often lead to injury and early mortality in the older adult. Age-related changes in postural control exist, and research has shown that poorer balance in older adults correlates directly with falls and fall risk.
LEARNING OBJECTIVES ARE TO:
1) Learn more about the relationship between falls and balance
2) Learn about the evidence related to balance performance and falling
3) Learn about the deficits in balance and how they relate to falls
4) Learn about pertinent information related to sensory integration that should be considered during clinical examinations
INFORMATION ABOUT THETOPIC
Balance or postural control is a multi-sensory, dynamic system that involves the somatosensory, visual, and vestibular sensory systems. In normal healthy adults without deficits these systems work together to generate appropriate automatic and anticipatory postural responses that allows for balance. However, when a deficit exists so to is balance in some form or fashion.
Beginning with the somatosensory system, when a deficit exists in this system, our body does not detect such things as vibration, touch, pressure, position, or motion as easily (Kenshalo, 1979). The somatosensory system is the primary source for balance maintenance and for triggering automatic postural responses (Inglis et. al, 1994). This system is also used to resolve sensory conflicts (Shumway-Cook & Horak, 1992). A loss in this part of the balance system is correlated with increased sway, gait problems, and falls (Rose, G. et al. 2014). Without this system helping to provide sensory cues to trigger motor responses, there is a greater likelihood for loss of balance or fall (Horak et al., 2005).
The second system that aids in balance and postural control is the visual system. In the visual system that lacks a pathology, there is an appropriate visual threshold, which is the amount of light it takes to see objects. In the absence of deficits, the visual system allows for viewing of the environment, there is visual acuity and contrast sensitivity, and an individual has meaningful depth perception and motion sensitivity, both of which contribute to good balance and postural control (Kwan et al. 2012). When an older adult has vision deficits, they will have a decreased ability to discriminate self vs. environmental motion, increasing the risk and likelihood of falling (Yip et al. 2014).
The third sensory system that contributes to balance is the vestibular system. In a functioning vestibular system, head perturbations trigger automatic postural controls. In addition to this function, it is thought to resolve sensory conflicts when vision and somatosensation do not agree (King, 2014). The vestibular system predicts balance performance of older adults on compliant surfaces with eyes closed. In conjunction with the other systems, when a vestibular deficit exist, there is an impairment in a person's ability to adapt, substitute, and compensate in movement (Muir et al. 2013). There ability to re-weigh to a sense is compromised.
WHO TO AND WHEN SHOULD I APPLY THISINFORMATION?
All information presented is in regards to the older adult whether healthy community dwelling or institutionalized. Whenever you are working with anyone over 65 or assessing balance and fall history of an individual, impairments in each of these areas should be examined and considered. The clinician should be aware that with more impairments, there will be a subsequent decrease in balance and postural control that will likely increase an individuals fall risk.
*This last resource is a great page to mark as it includes sources toward patient care, consumer education, CEU courses, and it provides additional related resources regarding Balance and Falls
REFERENCES
1) Kenshalo DR. Aging effects on cutaneous and kinesthetic. In: Han SS, Coons DH, eds. Special Senses in Aging. Ann Arbor: University of Michigan, 1979
2) Inglis JT, Horak FB, Shupert CL, Rycewicz C. The importance of somatosensory information in triggering and scaling automatic postural responses in humans. Exp Brain Res 1994; 101:161
3) Shumway-Cook A, Horak F. Balance Rehabilitation in the neurologic patient: course syllabus. Seattle: Neuroscience Education and Research Associates, 1992.
4) Horak FB, Dimitrova D, Nutt JG. Directional-specific postural instability in subjects with Parkinson's Disease. Exp Neurology 2005; 193: 504-521
5) Rose, G., Nordon-Craft, A., Jaffari, R., Patterson, RM., and Bugnariu, N. (2014). Ischemia-induced reduction of somatosensory input decreases balance; added vibratory noise partially restores function. American Physical Therapy Association Combined Section Meeting. Las Vegas, NV
6) Kwan MM, Lin SI, Close JC, Lord SR. Depressive symptoms in addition to visual impairment, reduced strength and poor balance predict falls in older Taiwanese people. Age Ageing. 2012;41(5):606-12.
7) Yip JL, Khawaja AP, Broadway D, et al. Visual acuity, self-reported vision and falls in the EPIC-Norfolk Eye study. Br J Ophthalmol. 2014;98(3):377-82.
8) Muir JW, Kiel DP, Hannan M, Magaziner J, Rubin CT (2013) Dynamic Parameters of Balance Which Correlate to Elderly Persons with a History of Falls. PLoS ONE 8(8): e70566. doi:10.1371/journal.pone.0070566 9) King, Laurie. (2014) Beyond the Vestibular System - Other Contributions to Balance Control. Perspectives on Hearing and Hearing Disorders: Research and Diagnostics, April 2014, Vol. 18, 16-23. doi: 10.1044/hhd18.1.16
Falls are prevalent in community dwelling older adults, with a higher prevalence in institutionalized older adults; they will often lead to injury and early mortality in the older adult. Age-related changes in postural control exist, and research has shown that poorer balance in older adults correlates directly with falls and fall risk.
LEARNING OBJECTIVES ARE TO:
1) Learn more about the relationship between falls and balance
2) Learn about the evidence related to balance performance and falling
3) Learn about the deficits in balance and how they relate to falls
4) Learn about pertinent information related to sensory integration that should be considered during clinical examinations
INFORMATION ABOUT THE TOPIC
Balance or postural control is a multi-sensory, dynamic system that involves the somatosensory, visual, and vestibular sensory systems. In normal healthy adults without deficits these systems work together to generate appropriate automatic and anticipatory postural responses that allows for balance. However, when a deficit exists so to is balance in some form or fashion.
Beginning with the somatosensory system, when a deficit exists in this system, our body does not detect such things as vibration, touch, pressure, position, or motion as easily (Kenshalo, 1979). The somatosensory system is the primary source for balance maintenance and for triggering automatic postural responses (Inglis et. al, 1994). This system is also used to resolve sensory conflicts (Shumway-Cook & Horak, 1992). A loss in this part of the balance system is correlated with increased sway, gait problems, and falls (Rose, G. et al. 2014). Without this system helping to provide sensory cues to trigger motor responses, there is a greater likelihood for loss of balance or fall (Horak et al., 2005).
The second system that aids in balance and postural control is the visual system. In the visual system that lacks a pathology, there is an appropriate visual threshold, which is the amount of light it takes to see objects. In the absence of deficits, the visual system allows for viewing of the environment, there is visual acuity and contrast sensitivity, and an individual has meaningful depth perception and motion sensitivity, both of which contribute to good balance and postural control (Kwan et al. 2012). When an older adult has vision deficits, they will have a decreased ability to discriminate self vs. environmental motion, increasing the risk and likelihood of falling (Yip et al. 2014).
The third sensory system that contributes to balance is the vestibular system. In a functioning vestibular system, head perturbations trigger automatic postural controls. In addition to this function, it is thought to resolve sensory conflicts when vision and somatosensation do not agree (King, 2014). The vestibular system predicts balance performance of older adults on compliant surfaces with eyes closed. In conjunction with the other systems, when a vestibular deficit exist, there is an impairment in a person's ability to adapt, substitute, and compensate in movement (Muir et al. 2013). There ability to re-weigh to a sense is compromised.
WHO TO AND WHEN SHOULD I APPLY THIS INFORMATION?
All information presented is in regards to the older adult whether healthy community dwelling or institutionalized. Whenever you are working with anyone over 65 or assessing balance and fall history of an individual, impairments in each of these areas should be examined and considered. The clinician should be aware that with more impairments, there will be a subsequent decrease in balance and postural control that will likely increase an individuals fall risk.
ADDITIONAL RESOURCES REGARDING FALLS AND BALANCES
- [FREE SOURCE for download] - Prevention of Falls in Community-Dwelling Older Adults: U.S. Preventive Services Task Force Recommendation Statement: http://annals.org/article.aspx?articleId=1305528&atab=7
- [FREE SOURCE for download] - Interventions for preventing falls in older people living in the community (Review) - The Cochrane Collaboration http://onlinelibrary.wiley.com/store/10.1002/14651858.CD007146.pub3/asset/CD007146.pdf v=1&t=ibsdj1g0&s=4ef1e59830292bcdc0fc2c482ecde5591c7de000
- [FREE SOURCE for download] - Assessment in Balance and Gait in the older adult at risk for falls in the clinical setting Resource: PDF - http://www.fresno.ucsf.edu/norcal/downloads/10trueblood%20assessment%20of%20balance%20gait%20in%20older%20adult%20(main%20lecture%203-16-11).pdf
- [FREE SOURCE for download] - Provided by the VA National Center for Patient safety: Balance Assessment Handbook: A component of the Falls Toolkit - http://stopfalls.aaans.org/wp-content/uploads/Balance-Assessment-Handbook-Component-of-the-Falls-Toolkit.pdf
- [FREE SOURCES for download] - http://www.apta.org/BalanceFalls/
*This last resource is a great page to mark as it includes sources toward patient care, consumer education, CEU courses, and it provides additional related resources regarding Balance and FallsREFERENCES
1) Kenshalo DR. Aging effects on cutaneous and kinesthetic. In: Han SS, Coons DH, eds. Special Senses in Aging. Ann Arbor: University of Michigan, 1979
2) Inglis JT, Horak FB, Shupert CL, Rycewicz C. The importance of somatosensory information in triggering and scaling automatic postural responses in humans. Exp Brain Res 1994; 101:161
3) Shumway-Cook A, Horak F. Balance Rehabilitation in the neurologic patient: course syllabus. Seattle: Neuroscience Education and Research Associates, 1992.
4) Horak FB, Dimitrova D, Nutt JG. Directional-specific postural instability in subjects with Parkinson's Disease. Exp Neurology 2005; 193: 504-521
5) Rose, G., Nordon-Craft, A., Jaffari, R., Patterson, RM., and Bugnariu, N. (2014). Ischemia-induced reduction of somatosensory input decreases balance; added vibratory noise partially restores function. American Physical Therapy Association Combined Section Meeting. Las Vegas, NV
6) Kwan MM, Lin SI, Close JC, Lord SR. Depressive symptoms in addition to visual impairment, reduced strength and poor balance predict falls in older Taiwanese people. Age Ageing. 2012;41(5):606-12.
7) Yip JL, Khawaja AP, Broadway D, et al. Visual acuity, self-reported vision and falls in the EPIC-Norfolk Eye study. Br J Ophthalmol. 2014;98(3):377-82.
8) Muir JW, Kiel DP, Hannan M, Magaziner J, Rubin CT (2013) Dynamic Parameters of Balance Which Correlate to Elderly Persons with a History of Falls. PLoS ONE 8(8): e70566. doi:10.1371/journal.pone.0070566
9) King, Laurie. (2014) Beyond the Vestibular System - Other Contributions to Balance Control. Perspectives on Hearing and Hearing Disorders: Research and Diagnostics, April 2014, Vol. 18, 16-23. doi: 10.1044/hhd18.1.16